Smoking cessation: advice and treatment in ... - Wiley Online Library

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Smoking cessation: advice and treatment in general practice Andy McEwen PhD and Eleni Vangeli MSc VM

The authors describe the the benefits of smoking cessation and discuss the advice and drug treatments that can be provided in primary care.

Figure 1. It is safe for patients to take the maximum dose of nicotine replacement therapy: patients often use too little and for an insufficient time

he introduction of smoke-free public places in Scotland in 2006, followed by the rest of the UK in 2007, was a huge step forward in the effort to reduce exposure to second-hand smoke. It also aimed to prevent the uptake of smoking, as did recent legislation that raised the legal age for purchasing tobacco to 18, and to encourage smokers to quit. Evidence that the legislation had an immediate impact is provided by the 165 000 people who are reported to have quit with the help of English and Welsh NHS Stop Smoking Ser vices between April and September 2007, an increase of

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28 per cent over the same period in 2006.1 However, the prevalence of smoking in the UK has declined relatively slowly over the last decade and is still more than 20 per cent of the adult population (see Figure 2). Smoking remains the single largest cause of morbidity and mortality in the UK (see Table 1) accounting for around 100 000 deaths in 2007.3 The health toll of tobacco use on individuals and communities is considerable, and the burden upon the economy heavy – treatment of smoking-related diseases alone costs the NHS approximately £1.5 billion a year.5

Behavioural support

NHS Stop Smoking Services were set up to provide specialist treatment for smokers wanting to stop. Treatment includes guidance on the appropriate use of medication, information and advice on coping with withdrawal symptoms and expert behavioural support. Treatment is delivered by specialist advisers over six or seven sessions at weekly intervals in groups or one to one. Both formats are shown to substantially increase longterm success, although data from NHS Stop Smoking Services show that group treatment is associated with slightly better success rates.6 www.prescriber.co.uk


Prevalence (per cent)

60

men women both

50 40 30 20 10 0 19

74 978 982 986 990 994 998 000 001 002 003 004 005 006 2 2 2 2 2 2 2 1 1 1 1 1 1

Figure 2. Smoking prevalence in the UK since 19742

Receiving support from the NHS Stop Smoking Ser vice doubles smokers’ chances of success, which approximately doubles again if medication is used.7 Medications

There are three types of medication available for smoking cessation in the UK: nicotine replacement therapy (NRT), varenicline (Champix) and bupropion (Zyban, see Table 2). In the absence of contraindications there is no evidence to discriminate between these medications and coronary heart disease cancers of the: lung, larynx, oral cavity, nasopharynx, oropharynx, hypopharynx, oesophagus, liver, cervix, stomach, urinary tract, kidney, ureter and bladder leukaemia chronic obstructive pulmonary disease aortic aneurism cerebrovascular disease peripheral vascular disease vascular dementia pneumonia

the National Institute for Health and Clinical Excellence (NICE) recommends that all three should be made available to smokers who want to stop and that no one medication should be favoured over another. 8 While varenicline and bupropion are prescription-only medicines, NRT is also available over the counter and some products, ie gum, patch and lozenge, are on general sale. Smoking cessation medications are usually supplied on an ‘abstinence contingent’ basis to avoid wastage. In other words, clients are asthma attacks surgical complications osteoporosis tuberculosis type II diabetes peptic ulcers macular degeneration cataract hearing loss sudden infant death syndrome spontaneous abortion stillbirth low birth weight infertility

Table 1. Disorders (fatal and serious nonfatal) for which tobacco use is a known or probable cause or an exacerbating factor4 50


only given a further supply if their continued abstinence is confirmed, by self-report and carbon monoxide (CO) validation, or if the clinician thinks there is a reasonable chance that abstinence will be achieved. NRT Maintaining long-term (over six months) abstinence with NRT compared to placebo has an odds ratio of 1.58. 7 There are no significant contraindications for NRT as it delivers therapeutic nicotine, ie without the tar and CO that cigarette smoke contains, but caution is advised with women who are pregnant or breastfeeding and for those under 18 years of age. In both cases patients would be best served by a referral to the local NHS Stop Smoking Service. Common sense also dictates that patients with plaster allergies or skin conditions should avoid the nicotine patch, and that those with false teeth may struggle with the nicotine gum – there is no evidence to match specific NRT products to ‘types’ of smokers, so choice is a matter of preference and can generally be left to the patient. One issue with NRT is that patients use too little and for an insufficient duration. Typically NRT delivers about half the nicotine from cigarettes, so it is safe and clinically effective to recommend that patients use the maximum dose stipulated or even combine products. Additionally, the lag time between using the product and peak blood nicotine levels is such that waiting for a craving and then taking NRT is going to be of little use to patients. Manufacturers’ instructions for use of oral products differ, but best clinical practice dictates recommending hourly use throughwww.prescriber.co.uk


Medication

Recommended daily dose

Duration of treatment

Side-effects

Cost per complete course12

NNT* for 1 long-term quitter

NRT

patch: 1 gum: 10-15 pieces Microtab: 15-20 tablets lozenges: 10-15 lozenges inhalator: 3-6 cartridges nasal spray: 1 squirt in each nostril regularly throughout the day

8-12 weeks initially; can be used for longer to prevent relapse

patch: local irritation of the skin may occur gum, Microtab, lozenges: burning sensation in mouth, dyspepsia if used incorrectly; aching jaw with the gum inhalator: local irritation in mouth and throat nasal spray: burning sensation in nostrils, sneezing and eyes may water

£120-£150

13-20

side-effects from NRT are minor and, if medication continues to be used as recommended, tolerance to them usually develops within 48 hours Varenicline

days 1-3: 0.5mg once daily days 4-7: 0.5mg twice daily day 8-end: 1mg twice daily patients with severe hepatic impairment 1mg once daily from day 4 onwards

12 weeks option for a further 12 weeks’ supply for those who feel they need it

nausea (mild to moderate), abnormal dreams, headache, insomnia

£164

5-11

Bupropion

days 1-6: 150mg once daily day 7-end: 150mg twice daily keep at least 8 hours between each dose elderly: 150mg once daily diabetes: full dose if diet controlled, 150mg once daily if controlled with insulin or oral hypoglycaemics, recommend NRT or varenicline if poorly controlled

7-9 weeks

dry mouth, sleeping difficulties and headache; seizures are rare (1 in 1000)

£80

10-17

*number needed to treat, ie number of smokers, on 15 or more cigarettes a day, treated to achieve 1 long-term (at least 6 months) quitter Table 2. Properties and cost of smoking cessation medications 52


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out the day to maintain blood nicotine levels to reduce withdrawal symptoms. Varenicline Achieving long-term abstinence with varenicline compared to placebo has an odds ratio of 3.22.9 Varenicline is licensed for any smoker over 18 years old, who is not pregnant or in end-stage

renal failure; caution should be exercised for smokers who are breastfeeding as it is not known whether varenicline is excreted in breast milk. There have been press reports of varenicline being linked to suicidal ideation and suicide; however there is no scientific evidence that supports this link.10 Smoking cessation, with or without treatment

Scenario: a patient consults you about a health matter that may or may not be smoking related Ask ‘I’d just like to ask you about smoking – are you a smoker, a nonsmoker or an ex-smoker?’

nonsmoker or longterm ex-smoker

record smoking status in computer and/or written notes

smoker record smoking status in computer and/or written notes Advise ‘You probably already know the risks involved with smoking, but I cannot stress enough how important it is to stop. It is the best thing that you can do to improve your health.’

not interested in stopping smoking at this record advice given and response in computer and/or time written notes; also suggest they may want to consider using NRT to help them cut down and possibly stop later

‘If you would like to give up smoking I can help you’ assist or record advice given and response in computer and/or written notes

record advice given and response in computer and/or written notes

Refer if you have access to a local Specialist Smoking Cessation Service as this offers smokers the best chance of quitting

Provide • smoking cessation treatment if the patient is not keen to attend local service or you yourself have been trained to specialist level • advice on smoking cessation medications • a supply of medication

‘Here is a referral card, just give our smoking cessation team a call. They are specialists and can really help you (are trained to make a difference).’

Figure 3. Brief smoking cessation advice6 54


with varenicline, is associated with various symptoms including depressed mood, and patients with a history of depression should be closely monitored. A recent study demonstrated that, when used by clients with a psychiatric illness, eg depression, varenicline was effective and there was no evidence that their illness was exacerbated.11 Bupropion Achieving long-term abstinence with bupropion compared to placebo has an odds ratio of 1.94.7 Bupropion has a more significant side-effect profile and is contraindicated in pregnant and breastfeeding patients, those under 18, patients with a history of epilepsy or seizure disorder, eating disorder, liver disorder and manic depression, and for those using MAOIs. Caution is also indicated with a number of other disorders and you should refer to the BNF. Role of the GP

Very brief advice to stop smoking from a GP leads to 1-3 per cent of patients stopping smoking for at least six months. 12 This advice appears to have its effect primarily by triggering a quit attempt rather than by increasing the chances of success of quit attempts. Despite the strong evidence of the efficacy of brief advice, the numbers quitting successfully are so small that GPs can think that their advice to quit is ineffective, especially as it may take a number of quit attempts before a smoker achieves long-term abstinence. Smoking cessation guidelines recommend that all health professionals should check on the smoking status of their patients at least once a year and advise smokers to stop. This brief advice can be delivered opportunistically during routine consultations to smokers, whether or not they are seeking www.prescriber.co.uk


Benefits of smoking cessation

Stopping smoking is the single most important action a person can take to improve their current and future health (see Table 3 and Figure 4). However, in the first few weeks of quitting patients may feel anything other than healthy as they suffer from the stress of giving up (making them more prone to cold sores, mouth ulcers and respiratory tract infections) and from withdrawal symptoms, eg urges to smoke, increased appetite, low mood and sleep disturbance. Continued abstinence will ensure that these diminish over time and the health benefits of smoking cessation are substantial, with the greatest benefit accrued www.prescriber.co.uk

Benefit within weeks reduced risk of sudden death from cardiac event continued steep decline in lung function halted reduced postoperative complication rate reduced risk of low birth weight in infants and complications of pregnancy reduced incidence of respiratory infections reduced severity of asthma attacks improved complexion Benefit within a year reduced risk of cardiovascular disease Benefit after several years rise in lung cancer risk is halted reduced risk of other cancers Table 3. Major health benefits of stopping smoking14

Lung function – FEV1 (% of value at age 25)

help with stopping smoking. Smokers may be more receptive to advice to stop when it is linked with an existing medical condition, not necessarily smoking related, and are happier to receive advice to stop when GPs link the advice to their reason for visiting the surgery. The key elements of brief smoking cessation advice are: ask if the person smokes, advise smokers to quit and, if they would like help, refer them to the NHS Stop Smoking Service, or if they do not want to attend the Ser vice, then where possible offer an alternative. When patients respond that they do not want to stop smoking, or are not interested in attempting to quit at this time, then they can be informed that NRT products are now available to help smokers cut down the amount of cigarettes that they smoke before they stop. Smokers cutting down with the help of NRT are more likely to make a genuine reduction in their smoking, and to stop completely, than smokers who cut down without the use of NRT.

100

75

50

25

0 25

50 Age (years)

75

susceptible smoker never smoked or not susceptible to smoke stopped smoking at 45 stopped smoking at 65 disability death Figure 4. Decline in lung function in smokers and nonsmokers

by those smokers with no smoking-related disease who stop smoking before they reach 35 years of age: they can have a normal life-expectancy. Smokers who stop later on in life, even into their 70s, can still expect to significantly reduce their risk of premature death. Smoking cessation inter ventions are considerably more cost

effective than most medical lifesaving inter ventions. NICE typically recommends a treatment to the NHS if it costs less than £20 000-£30 000 for each life year gained (LYG). Statins cost almost £25 000 per LYG, whereas behavioural support plus a course of medication for smoking cessation costs around £1000 or less per LYG.15 Prescriber 5 October 2008

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Stop smoking resources for patients NHS Stop Smoking website NHS website offering information, advice and support and a link to find a local NHS Stop Smoking Service: www.gosmokefree.nhs.uk NHS Smoking Helpline Help and advice to quit by telephone: 0800 022 4 332 (free) QUIT Expert assistance to quit by telephone: 0800 00 22 00 (free), or online: www.quit.org.uk No Smoking Day Organisation providing help to smokers wanting to quit on No Smoking Day: www.nosmokingday.org.uk Stop smoking resources for health professionals Manual of Smoking Cessation by Andy McEwen, Peter Hajek, Hayden McRobbie, et al. A useful, practical guide on how to conduct both brief and specialist cessation interventions with examples of how best to communicate information to patients. Gives the essential facts about smoking, the benefits of stopping and medications. www.blackwellpublishing.com. Smoking Cessation Service Research Network (SCSRN) The best one-stop website for clinical, research and policy resources; www.scsrn.org. UK National Smoking Cessation Conference (UKNSCC) An annual conference to assist the professional development of the field. The conference website has a permanent free archive of conference abstracts, presentation notes, powerpoint presentations and delegate reports. www. uknscc.org. Smoking Cessation: Fast Facts (2nd edition) by Robert West and Saul Shiffman Published in 2008 it gives practical advice for interventions, along with current information about the effects of smoking, the consequences of smoking cessation and the myths about smoking and quitting. www.healthpress.co.uk.

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Stopping smoking does not just add years to life, it adds life to years. Ex-smokers cannot only expect a longer life than those who continue to smoke, but a healthier life as well. Former smokers experience fewer days of illness than current smokers, are fitter and feel much healthier. References

1. The Information Centre for Health and Social Care. Statistics on NHS Stop Smoking Ser vices in England, AprilSeptember 2007 (Q2 – quarterly report). 2008. 2. Goddard E. General household survey, 2006: smoking and drinking among adults, 2006. Newport: Office of National Statistics, 2008. 3. West R. Smoking: prevalence, mortality and cessation in Great Britain. 2007. www.rjwest.co.uk/resources/smoking cessation.doc. 4. West R. Tobacco control: present and future. Br Med Bull 2006;77-78: 123-36. 5. Parrott S, Godfrey C. Economics of smoking cessation. BMJ 2004;328 (7445):947-9. 6. McEwen A, Hajek P, McRobbie H, et al. Manual of smoking cessation: a guide for counsellors and practitioners. London: Blackwell, 2006. 7. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Health Education Authority. Thorax 2000;55(12):987-99. 8. National Institute for Health and Clinical Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for

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